Mid and South Essex NHS Foundation Trust
NHS Trust
Action Taken
AI-generated response summary
The Trust has increased staffing in the Emergency Department, introduced new policies and protocols for deteriorating patients, and established new roles and audits to improve patient identification and escalation. It has also implemented a Learning Response Decision Tool for incident investigations and reverted the sepsis proforma to paper, while planning further IT integration.
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Dear Sir, Inquest touching on the death of Miss Millie Jade Hook - Regulation 28 Report I write further to your Regulation 28 Report to Prevent Future Deaths dated 15 July 2026 issued for Mid and South Essex NHS Foundation Trust (‘the Trust’), relating to the Inquest of Miss Millie Hook. Senior colleagues have carefully considered your concerns and set out our formal response to each matter using your numbering as follows. Matters of Concern
1. There is a concern that the systems for dealing with patients in the Emergency Department at Basildon Hospital presenting with acute physiological derangement and who are clearly unwell, is inadequate. This includes: (a) the appropriate emergency care pathway and the effectiveness of the interface between the hospital teams and departments. (b) There is also concern that cases are not being appropriately escalated to senior clinicians in a timely manner; The Deputy Director of Nursing for Basildon Hospital has confirmed that, since this incident, detailed reviews of the medical and nursing skill mix in the Emergency Department (ED) have led to funded staffing increases in both workforces, strengthening the team’s clinical capacity. This has included an additional 2 x senior doctor posts, plus a significant increase of 27 registered nurses (5 per shift) and 22 health care assistants (4 per shift). Whilst recruitment is underway these places are successfully filled with temporary staffing options with an ever-decreasing vacancy rate. The Trust has also introduced a revised ED specific policy; Internal Professional Standards, ref: and supporting protocol; Deteriorating Patient Escalation ED, which are attached. The policy focuses on ensuring the safe management of patients attending the emergency department, defining clinical ownership within the department and sets out the appropriate escalation routes. It is further enhanced with the local guidance document to support rapid escalation. Chairman: Dr Andy Wood OBE 1 Chief Executive: Adam Sewell-Jones 7
[Page 2] A weekly deteriorating-patient audit is now undertaken to assess whether acutely unwell patients in the ED are identified and escalated appropriately. It reviews the accuracy of the National Early Warning Score (‘NEWS’), the timeliness of escalation and repeat observations, and records hospital numbers to enable detailed case review where required. The results attached demonstrate the embedded and ongoing strong compliance in terms of timeliness of observations recorded and the subsequent escalation and repeating of those observations, indicating that deteriorating patients are identified and escalated appropriately. We continue to focus on those areas where compliance has not been sustained, largely around observations recorded on leaving the department, not those related to deterioration. The ED has also introduced a Deteriorating Patient Nurse role to support staff in identifying clinical deterioration and escalating those patients that require prompt senior clinical review. In addition, weekly audits of referrals from the ED to Critical Care now monitor response and transfer times. Any issues identified are escalated through the Trust’s established governance channels. The ED has also established a waiting-room team comprising a registered nurse and a Healthcare Assistant (HCA). The team provides clinical oversight and supports the prompt identification of critically ill patients on arrival in the department. Weekly audits assess the effectiveness of this role. The audit focuses on two key elements of assurance, including confirmation that the team were present in the waiting room, and that they undertook the specific roles and responsibilities of the role. This is confirmed by a review of staff allocation sheets and a documented daily log of actions undertaken by the waiting room team. This remains a very well evidenced intervention with the registered nurse allocations demonstrating 100% cover and the documentation demonstration strong compliance in terms of the role. The audit is attached for reference.
2. There is a concern that those working in substantive consultancy posts at Basildon Hospital and other hospitals in the Trust, including in departments to which critically ill patients may be taken and where the care that such patients receive might affect whether they survive or not, do not hold the appropriate consultant registration standard and that the continued employment of such consultants on a long- term basis does not meet the appropriate NHS standards for holding and maintaining employment in such positions; Our Chief Medical Officer has provided assurance that the Trust only employs suitably qualified doctors holding specialist registration to substantive permanent consultant posts. In circumstances where the consultant vacancy cannot be filled by a consultant on the specialist register, or the Trust has a temporary gap, (for example due to a sabbatical or maternity leave), we may appoint a locum or fixed term consultant without specialist registration in line with National guidance. 8
[Page 3] NHS Employers: Guidance for the employment of medical and dental consultants- "Specialist registration is not a legal requirement for appointment to consultant posts in NHS foundation trusts. However, foundation trusts must still ensure that any doctor they appoint, whether or not they are on the specialist register, has the current competence to undertake all the duties of the post". In Millie’s case, one of the critical care consultants who was involved in her care had the following qualifications and designation as detailed; MBBCh, MSc, EDIC, FFICM, EDEC, Locum Consultant in Intensive Care Medicine. This doctor was appointed in 2023 through a competitive process and has both European & UK Fellowship qualifications in intensive care medicine. The annual appraisal process for locum consultants who are not on the specialist register is the same process as for substantive consultants and provides assurance to the Trust's Responsible Officer and the General Medical Council (GMC) that the doctor remains up to date and fit to practice. Locum consultants are entitled to supporting professional activity, training, and continuing professional development time and funding in the same way as substantive consultants. Locum consultants within the Trust have an annual job plan agreed with their Clinical Director which defines their scope of practice in line with their skills and qualifications.
3. There is a concern over the effectiveness and sufficiency of the Trust’s arrangements for investigating cases where patients have died or where there have been other serious outcomes, including not properly obtaining and considering additional clinical opinion, not investigating promptly, and seeking to sufficiently to implement learning from such incidents. We recognise that high-quality incident reviews undertaken in accordance with the Patient Safety Incident Response Framework (PSIRF) are essential to identifying learning and delivering sustainable improvements through effective safety actions. Established processes support the management of incidents in line with PSIRF principles, including proportionate responses informed by a range of learning response methods and supported by appropriate guidance, tools, and templates. Where a patient has died or experienced severe harm, a learning response is required in response to the incident. Under a revised process introduced in Quarter 1 of 2026/27, a Learning Response Decision Tool (LRDT) must be completed for incidents that meet our Patient Safety Incident Response Plan (PSIRP). The LRDT is based on the SBAR principles of Situation, Background, Assessment and Recommendation, which supports structured decision-making to determine the most proportionate learning response and to identify early learning and associated actions. Where the LRDT identifies further opportunities for learning which need to be managed through an additional learning response to investigate the incident, using an appropriate systems-based investigation. For incidents that meet the PSIRF plan, the LRDT is presented to a decision-making panel to determine next steps in management of specific incidents or where there is deemed to be significant learning. All learning responses are signed off within a Site by either the Site Director of Nursing, Site Medical Director (or a designated deputy) prior to this meeting. 9
[Page 4] The Trust has processes in place to facilitate management of all incident-related items through the use of the Datix system, a weekly Key Performance Indicator (KPI) report and weekly incident oversight reports that are shared to site leadership teams, to facilitate their oversight of items that they are responsible and accountable for. There are multiple processes for quality checking, quality assurance, and escalation of incidents across all layers of the incident processes. At the Basildon site, the Site Senior Leadership Team maintains oversight of divisional incident learning responses through weekly incident review meetings where the governance teams escalate concerns or delays. There is a focus within the ED to implement learning and monitor learning outcomes with regular safety briefs. Management of incidents under PSIRF is maturing within the Trust, and continues to embed and develop following national guidance, feedback, and learning from learning response completion. The organisation has a process in place to undertake an annual review of PSIRF and consider further embedding steps and areas of focus for the next financial year to compliment the ongoing and continuous consideration for improvements. Specifically in reviewing deaths, the Trust plans to move Structured Judgement Reviews (SJRs) within the existing risk management system (Datix). This will streamline and strengthen the triangulation of information relating to deaths by bringing relevant information together within a single system, rather than requiring review across multiple systems. This approach also supports learning under the learning from deaths framework. The Trust are currently actively reviewing how we implement a revised process for inquest preparation which includes the review of existing incidents and any requirements to incident report during inquest preparation process. This will move away from the current process of reporting all inquests as incidents, thereby aligning to national guidance, and ensuring that proportionate learning responses are applied and opportunities for learning are harnessed when indicated using the PSIRF approach.
4. There is a concern as to whether there is a pro- forma sepsis protocol in use at Basildon Hospital, and if there is, how this protocol is being deployed and whether clinical interventions pursuant to this protocol are being adequately recorded. The Deputy Director of Nursing has confirmed that Basildon Hospital site had a sepsis protocol in place at the time of Millie’s death and continues to use it. Developed in line with national guidance, the protocol supports the safe and timely management of patients presenting with signs and symptoms of sepsis. It includes a proforma for recording and capturing specific clinical interventions. At the time of this incident, the proforma was included in the electronic observations system, but following determination that this was poorly completed, this has since returned to a paper form. The pathway continues to be reviewed and regularly updated in line with best practice standards, even when captured electronically or on paper. 10
[Page 5] There are monthly audits of both adherence to the quality standards as well as completion of the associated proforma, which show strong compliance. I have attached recent data from these audits to evidence our compliance results of 86 – 100% across the last 4 months. (Sepsis Data April – July 2026) We are currently in the process of developing an integrated IT system (NOVA) for a unified digital patient record system, which will include electronic recording of observations. The potential of linking this to a e-sepsis proforma is actively being explored with the NOVA development team. We understand that the Court will share a copy of this reply with Millie’s family; we hope that we have provided assurance that we have taken meaningful learning from her experience and we are committed to ensuring our improvements are sustained. If I can assist you further in this case, please do not hesitate to contact me.
1. There is a concern that the systems for dealing with patients in the Emergency Department at Basildon Hospital presenting with acute physiological derangement and who are clearly unwell, is inadequate. This includes: (a) the appropriate emergency care pathway and the effectiveness of the interface between the hospital teams and departments. (b) There is also concern that cases are not being appropriately escalated to senior clinicians in a timely manner; The Deputy Director of Nursing for Basildon Hospital has confirmed that, since this incident, detailed reviews of the medical and nursing skill mix in the Emergency Department (ED) have led to funded staffing increases in both workforces, strengthening the team’s clinical capacity. This has included an additional 2 x senior doctor posts, plus a significant increase of 27 registered nurses (5 per shift) and 22 health care assistants (4 per shift). Whilst recruitment is underway these places are successfully filled with temporary staffing options with an ever-decreasing vacancy rate. The Trust has also introduced a revised ED specific policy; Internal Professional Standards, ref: and supporting protocol; Deteriorating Patient Escalation ED, which are attached. The policy focuses on ensuring the safe management of patients attending the emergency department, defining clinical ownership within the department and sets out the appropriate escalation routes. It is further enhanced with the local guidance document to support rapid escalation. Chairman: Dr Andy Wood OBE 1 Chief Executive: Adam Sewell-Jones 7
[Page 2] A weekly deteriorating-patient audit is now undertaken to assess whether acutely unwell patients in the ED are identified and escalated appropriately. It reviews the accuracy of the National Early Warning Score (‘NEWS’), the timeliness of escalation and repeat observations, and records hospital numbers to enable detailed case review where required. The results attached demonstrate the embedded and ongoing strong compliance in terms of timeliness of observations recorded and the subsequent escalation and repeating of those observations, indicating that deteriorating patients are identified and escalated appropriately. We continue to focus on those areas where compliance has not been sustained, largely around observations recorded on leaving the department, not those related to deterioration. The ED has also introduced a Deteriorating Patient Nurse role to support staff in identifying clinical deterioration and escalating those patients that require prompt senior clinical review. In addition, weekly audits of referrals from the ED to Critical Care now monitor response and transfer times. Any issues identified are escalated through the Trust’s established governance channels. The ED has also established a waiting-room team comprising a registered nurse and a Healthcare Assistant (HCA). The team provides clinical oversight and supports the prompt identification of critically ill patients on arrival in the department. Weekly audits assess the effectiveness of this role. The audit focuses on two key elements of assurance, including confirmation that the team were present in the waiting room, and that they undertook the specific roles and responsibilities of the role. This is confirmed by a review of staff allocation sheets and a documented daily log of actions undertaken by the waiting room team. This remains a very well evidenced intervention with the registered nurse allocations demonstrating 100% cover and the documentation demonstration strong compliance in terms of the role. The audit is attached for reference.
2. There is a concern that those working in substantive consultancy posts at Basildon Hospital and other hospitals in the Trust, including in departments to which critically ill patients may be taken and where the care that such patients receive might affect whether they survive or not, do not hold the appropriate consultant registration standard and that the continued employment of such consultants on a long- term basis does not meet the appropriate NHS standards for holding and maintaining employment in such positions; Our Chief Medical Officer has provided assurance that the Trust only employs suitably qualified doctors holding specialist registration to substantive permanent consultant posts. In circumstances where the consultant vacancy cannot be filled by a consultant on the specialist register, or the Trust has a temporary gap, (for example due to a sabbatical or maternity leave), we may appoint a locum or fixed term consultant without specialist registration in line with National guidance. 8
[Page 3] NHS Employers: Guidance for the employment of medical and dental consultants- "Specialist registration is not a legal requirement for appointment to consultant posts in NHS foundation trusts. However, foundation trusts must still ensure that any doctor they appoint, whether or not they are on the specialist register, has the current competence to undertake all the duties of the post". In Millie’s case, one of the critical care consultants who was involved in her care had the following qualifications and designation as detailed; MBBCh, MSc, EDIC, FFICM, EDEC, Locum Consultant in Intensive Care Medicine. This doctor was appointed in 2023 through a competitive process and has both European & UK Fellowship qualifications in intensive care medicine. The annual appraisal process for locum consultants who are not on the specialist register is the same process as for substantive consultants and provides assurance to the Trust's Responsible Officer and the General Medical Council (GMC) that the doctor remains up to date and fit to practice. Locum consultants are entitled to supporting professional activity, training, and continuing professional development time and funding in the same way as substantive consultants. Locum consultants within the Trust have an annual job plan agreed with their Clinical Director which defines their scope of practice in line with their skills and qualifications.
3. There is a concern over the effectiveness and sufficiency of the Trust’s arrangements for investigating cases where patients have died or where there have been other serious outcomes, including not properly obtaining and considering additional clinical opinion, not investigating promptly, and seeking to sufficiently to implement learning from such incidents. We recognise that high-quality incident reviews undertaken in accordance with the Patient Safety Incident Response Framework (PSIRF) are essential to identifying learning and delivering sustainable improvements through effective safety actions. Established processes support the management of incidents in line with PSIRF principles, including proportionate responses informed by a range of learning response methods and supported by appropriate guidance, tools, and templates. Where a patient has died or experienced severe harm, a learning response is required in response to the incident. Under a revised process introduced in Quarter 1 of 2026/27, a Learning Response Decision Tool (LRDT) must be completed for incidents that meet our Patient Safety Incident Response Plan (PSIRP). The LRDT is based on the SBAR principles of Situation, Background, Assessment and Recommendation, which supports structured decision-making to determine the most proportionate learning response and to identify early learning and associated actions. Where the LRDT identifies further opportunities for learning which need to be managed through an additional learning response to investigate the incident, using an appropriate systems-based investigation. For incidents that meet the PSIRF plan, the LRDT is presented to a decision-making panel to determine next steps in management of specific incidents or where there is deemed to be significant learning. All learning responses are signed off within a Site by either the Site Director of Nursing, Site Medical Director (or a designated deputy) prior to this meeting. 9
[Page 4] The Trust has processes in place to facilitate management of all incident-related items through the use of the Datix system, a weekly Key Performance Indicator (KPI) report and weekly incident oversight reports that are shared to site leadership teams, to facilitate their oversight of items that they are responsible and accountable for. There are multiple processes for quality checking, quality assurance, and escalation of incidents across all layers of the incident processes. At the Basildon site, the Site Senior Leadership Team maintains oversight of divisional incident learning responses through weekly incident review meetings where the governance teams escalate concerns or delays. There is a focus within the ED to implement learning and monitor learning outcomes with regular safety briefs. Management of incidents under PSIRF is maturing within the Trust, and continues to embed and develop following national guidance, feedback, and learning from learning response completion. The organisation has a process in place to undertake an annual review of PSIRF and consider further embedding steps and areas of focus for the next financial year to compliment the ongoing and continuous consideration for improvements. Specifically in reviewing deaths, the Trust plans to move Structured Judgement Reviews (SJRs) within the existing risk management system (Datix). This will streamline and strengthen the triangulation of information relating to deaths by bringing relevant information together within a single system, rather than requiring review across multiple systems. This approach also supports learning under the learning from deaths framework. The Trust are currently actively reviewing how we implement a revised process for inquest preparation which includes the review of existing incidents and any requirements to incident report during inquest preparation process. This will move away from the current process of reporting all inquests as incidents, thereby aligning to national guidance, and ensuring that proportionate learning responses are applied and opportunities for learning are harnessed when indicated using the PSIRF approach.
4. There is a concern as to whether there is a pro- forma sepsis protocol in use at Basildon Hospital, and if there is, how this protocol is being deployed and whether clinical interventions pursuant to this protocol are being adequately recorded. The Deputy Director of Nursing has confirmed that Basildon Hospital site had a sepsis protocol in place at the time of Millie’s death and continues to use it. Developed in line with national guidance, the protocol supports the safe and timely management of patients presenting with signs and symptoms of sepsis. It includes a proforma for recording and capturing specific clinical interventions. At the time of this incident, the proforma was included in the electronic observations system, but following determination that this was poorly completed, this has since returned to a paper form. The pathway continues to be reviewed and regularly updated in line with best practice standards, even when captured electronically or on paper. 10
[Page 5] There are monthly audits of both adherence to the quality standards as well as completion of the associated proforma, which show strong compliance. I have attached recent data from these audits to evidence our compliance results of 86 – 100% across the last 4 months. (Sepsis Data April – July 2026) We are currently in the process of developing an integrated IT system (NOVA) for a unified digital patient record system, which will include electronic recording of observations. The potential of linking this to a e-sepsis proforma is actively being explored with the NOVA development team. We understand that the Court will share a copy of this reply with Millie’s family; we hope that we have provided assurance that we have taken meaningful learning from her experience and we are committed to ensuring our improvements are sustained. If I can assist you further in this case, please do not hesitate to contact me.